Initial Evaluation
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In-Home Visit & Consent?
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In-home Covid-19 Screening Questions last 48 hours
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Virtual session & Consent
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Patient Location Address & County at time of Virtual Session
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Where was the patient during the virtual session?
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Subjective
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Patient's present complaint
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Date symptoms first started
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History of present complaint
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Has the patient had prior treatments?
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Describe previous treatments
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Symptoms
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Investigations and Imaging
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Pain
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MSK-HQ initial eval score
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Current Verbal Numeric Pain Rating Scale
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Pain at Best (0-10) & Type
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Paint at Worst (0-10) & Type
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Aggravating Factors & Time
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Easing Factors & Time
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24 hour pain pattern
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Morning pain
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During the day
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At night
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Red Flag Signs
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The patient reports no red flags
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S4 Signs
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Details on S4 Sign
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Lumbar
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Details on Lumbar Signs
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Cervical artery
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Details on Cervical Artery Signs
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Cervical Instability
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Details on Cervical Instability
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Knee
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Details on Knee
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Past Medical History
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Past Conditions
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Please provide detail on past conditions
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Medications and allergies
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Social History and Psychosocial Factors
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Occupation, Activities/Hobbies
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Has worrying thoughts about pain / condition
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Please explain
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Feels that their pain is terrible and it is never going to get better
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Please explain
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Feels that they are avoiding activities because of their pain
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Please explain
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Patient goals and expectations
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Patient specific goals (SMART)
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Patient expectations of treatment
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Objective
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Observations / posture / gait
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Range of motion
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Neurological & Neurodynamic testing
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Muscle testing
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Functional Tests
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Observed Moment Dysfunction
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Special tests
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Palpation - positive findings
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Assessment
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Assessment
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Diagnosis
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Plan
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Plan - Include Freq/Duration (e.g. 1-2/wk for 8 weeks)
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3 Short-term Goals (SMART)
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3 Long-term goals (SMART)
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Treatment Procedures
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Evaluation complexity
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Interventions & TIme
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Is this a DIRECT ACCESS patient? (for physician signature)
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Is this a Medicare Patient?
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Certification effective from (mm/dd/yyyy Eval)
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Certification end mm/dd/yyyy (Eval + 90day)
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To Be Completed By Physician (Medicare Certification)
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Billing can be found in the H&P and SOAP sections
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PROGRESS NOTE
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Diagnosis (do not include ICD codes)
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# of Completed Appointments
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# of Cancellations
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# of No Shows
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SUBJECTIVE
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Subjective Findings
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Other Subjective Findings
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Current Verbal Numeric Pain Rating Scale
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% Overall Improvement
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Pain at Best (0-10) & Type
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Paint at Worst (0-10) & Type
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MSK-HQ
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OBJECTIVE FINDINGS
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Todays Objective Findings
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Todays Treatment
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ASSESSMENT
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Assessment Description
• • •
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Other Assessment Description
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Potential to reach goals
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Overall Assessment
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Problem List
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Notes
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PLAN
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GOALS
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Short Term Goal #1
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Goal Status
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Short Term Goal #2
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Goal Status
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Short Term Goal #3
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Goal Status
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Long Term Goal #1
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Goal Status
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Long Term Goal #2
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Goal Status
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Long Term Goal #3
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Goal Status
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Additional goals from Initial Eval
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Recommended Treatment Plan + Frequency & Weeks
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Plan of Care (POC)
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Expected # of Remaining Visits
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To be completed by Physician
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To Be Completed By Physician
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